Comorbidity - Diabetes Mellitus

Question 1

What are the symptoms of type 1 diabetes?

Answer 1

Weight loss, fat breakdown, inability to metabolize nutrients, polyuria and polydipsia (kidneys attempt to rid bloodstream of excess glucose)

Question 2

What is the medical treatment for type 1 diabetes?

Answer 2

Exogenous insulin

Question 3

List the symptoms of type 2 diabetes.

Answer 3

Increased thirst, frequent urination, hunger, fatigue, blurred vision, in some cases no symptoms

Question 4

What is the treatment for type 2 diabetes?

Answer 4

Diet, exercise
Oral medications or insulin
< 10% successfully managed with lifestyle changes alone

Question 5

List the disease factors influencing illness management of type 2 diabetes.

Answer 5

Slow/insidious onset
Diagnosed during routine medical examination –> disturbing experience
Diabetes progresses (even with self-management) –> hopelessness

Question 6

List the disease factors of both types of diabetes mellitus which influence illness management.

Answer 6

Various diabetic complications
Risk of hyperglycaemia and hypoglycaemia
BG maintained at levels near normal range = progression and diabetic complications significantly reduced

Question 7

List some regimen factors influencing illness management.

Answer 7

High complexity
Intrusiveness lifestyle
Significant costs
Discomfort/pain
Activities are multifactorial
Ongoing consistency/daily activity
Treatment regimens can change over course of treatment
= distress, loss of convenience/freedom/flexibility
= frustration –> regimen related demands different from non-medical social understanding
= patients have to educate others

Question 8

List individual factors influencing illness management.

Answer 8

Patient's health literacy 
Cultural illness beliefs 
Perceived social support 
Patient identity & perceptions 
Individual coping styles 
Coping = lifelong process 
Lower quality of life 
"Diabetes burnout" 
Coping/emotional distress in family members

Question 9

Describe the psychological impact of type 1 diabetes.

Answer 9

Medication routine interferes with ability to live normal life
Freedom to eat as I wish is affected
Increased risk of depression
Elevated “diabetes distress”
Children: initially psychological resilience –> 37% at least one diagnosis of mental health problem
Adolescence: greater diabetes distress –> more depressive symptoms –> higher BG level

Question 10

Explain the psychological impact of type 2 diabetes.

Answer 10

Short-term psychological impact limited
Longer term: risk of depression & diabetes-specific distress (comorbid conditions, diabetes complications)
Depression -> less optimal selfcare behaviours, suboptimal glycaemic control, higher mortality rates

Question 11

What is the neuropsychological impact of diabetes on children?

Answer 11

Decreased visuospatial and psychomotor, decreased attentional skills

Question 12

Discuss the neuropsychological impact of severe hypoglycaemia.

Answer 12

EEG abnormalities
School absence –> decreased verbal/achievement scores
Decreased psychomotor efficiency in children

Question 13

Discuss the neuropsychological impact of severe hyperglycaemia.

Answer 13

Decreased verbal skills, decreased visuomotor integration
Slower brainstem auditory evoked potentials, increased abnormality in MRI scans
Mild impairment of memory/learning performance
Decreased attention, decreased psychomotor efficiency, decreased spatial information processing
Intensive regimens = increased risk of hypoglycaemia = neural damage

Question 14

What are the effects of type 2 diabetes in the elderly?

Answer 14

Similar deficits in learning/memory related to metabolic control.

Question 15

List the comorbid psychopathology of diabetes and depression in type 1. (psychosocial factors)

Answer 15

Childhood adversity

Negative influence on personality development

Question 16

List the comorbid biological risk factors of type 2 diabetes and depression.

Answer 16

Immune dysfunction 
Dysregulation of HPA axis 
Inflammatory processes 
Circadian dysregulation 
Changes of gut microbiome/brain-gut axis 
Homeostatic dysregulation

Question 17

Describe the comorbid psychopathology of anxiety and diabetes.

Answer 17

14% GAD, 40% elevated anxiety symptoms
25% PTSD symptoms
PTSD symptoms in parents of children with newly diagnosed T1DM: 24% of mothers, 22% of fathers

Question 18

Describe the comorbid psychopathology of dysregulated eating and diabetes.

Answer 18

T1DM: 16% eating disorder
Increase subclinical levels of dysregulated eating
Increased body dissatisfaction
Anorexia nervosa: no higher prevalence rates, but more impact in death rates
Bulimia nervosa: increased prevalence, 60-80% binge eating
Intentionally omitting or underdosing insulin for weight control: 30% of adolescents with DM

Question 19

Describe the comorbid psychopathology of other mental disorders and diabetes.

Answer 19

Psychosis - atypic antipsychotic agents (clozapine, olanzapine) can induce diabetes
Substance use disorders
Somatic symptom disorders/somatoform disorders
OCD

Question 20

Name some self report tools used for diabetes mellitus.

Answer 20

Problem Areas in Diabetes Survey PAID
Attitude to Diabetes Scale ATT39
Insulin Treatment Appraisal Scale ITAS
Hypoglycaemic Fear Survey II - Worry Scale

Question 21

Describe how to bring bad news according to SPIKES

Answer 21

Setting up 
Perception 
Invitation 
Knowledge 
Emotions 
Strategy & Summary

Question 22

What is the role of the patient in communication?

Answer 22

Adherence
Empowerment & Self-management - enable person to make autonomous, informed decisions
Shared decision making - education, agreement on therapy goals/treatment preferences
Patient-centered approach
Monitoring psychological wellbeing routinely

Question 23

Name the ABCs of effective communication.

Answer 23

Active listening 
Body language
Clarify information and paraphrase 
Develop rapport 
Explain clearly 
Feedback 
Give clear signals 
Hear the sound of silence
In conclusion

Question 24

What are the psychosocial aspects of diabetes management?

Answer 24

Education 
Blood glucose monitoring 
Sexual dysfunction 
Weight management 
Comorbid mental health problems

Question 25

Describe education in diabetes management.

Answer 25

Diabetes knowledge
Diabetes management skills
Coping skills
Lifestyle change 
Reducing barriers 
Maintaining quality of life 
Reducing diabetes related distress
Accepting diabetes as part of everyday life

Question 26

How do you monitor blood glucose?

Answer 26

Blood Glucose Awareness Training (BCAT)

• Learn to identify best internal cues of extreme levels of BG
• Learn to anticipate extreme levels of BG based on info concerning insulin, food, exercise
• Learn to take appropriate action

Question 27

Describe how you treat DM-related sexual dysfunction.

Answer 27

Men & women affected
Men with DM respond less well to range of medical ED treatments
Predictors in men: age, BMI, DM duration, complications
Predictors in women: depression, poor partner relationships
Combine pharmalogical and psychological interventions

Question 28

Explain weight management programmes.

Answer 28

Nutrition education, behaviour modification, very low calorie diets, exercise.
Increased weight loss = problem : decreased weight loss maintenance
Encouraging weight maintenance rather than weight loss
Increased glycaemic control

Question 29

Psychological Interventions for Emotional Problems in diabetes.

Answer 29

Psyc

Question 30

Psychological Interventions for Emotional Problems in diabetes.

Answer 30

Psychological and pharmalogical interventions: decreased depression & diabetes distress
Evidence-based interventions: web based CBT, mindfulness based therapy, moderate effects in short term, small effects in long term
SSRI: short term: moderate to large effects –> decreased depression and small effects of increased glycaemic control.
Collaborative care/stepped care: moderate effect –> decreased depression, increased glycaemic control
Psychological interventions to reduce fear of hypoglycaemia : education - awareness of warning signs/reduce exposure to severe hypoglycaemia